HIV: Gay Again

On Dec. 19, 2012, the Centers for Disease Control and Prevention (CDC) released a report, "Estimated HIV Incidence in the United States, 2007-2010." To gay readers who'd lived through the AIDS epidemic, the document presented a landscape eerily like the early plague years, when AIDS was a gay disease. In 2010, 66 percent of new HIV infections, 31,800, were in "men who have sex with men" (MSM, a category that includes gay and bisexual guys and transgender women), though they account for less than 2 percent of the population. Between 2008 and 2010, new infections rose 12-percent for gay men while falling or remaining stable in all other populations. Transmission for young gay men spiked upwards 22 percent. MSM faced 30 times the HIV risk that straight guys faced. A gay African-American man was six times likelier to be infected with HIV than a white gay man, and a Hispanic man was three times likelier. Researcher Ron Stall's 2009 prediction that more than half of young gay men would be HIV-positive by age 50 suddenly seemed a chilling underestimate.

In the early 1980s, faced with seeming extinction, gay men invented safer sex. Supported by pamphlets, videotapes and workshops, promulgated across gay sexual networks, safer sex emphasized lower-risk sex acts and using condoms for high-risk anal sex. Empowered to take control of their lives in the face of a deadly virus, gay guys drove HIV incidence down by 75 percent between 1984 and 1993. Believing that safer sex was all the prevention we'd ever need, we who were AIDS activists never fought for prevention research or the development of new prevention tools. We focused on securing treatments for the sick and potentially sick.

But we were wrong to think the original community consensus behind safer sex could survive an evolving epidemic. As early as 1993, even as AIDS deaths mounted, HIV incidence for gay men began a slow upward drift. Combination antiretroviral therapy, introduced in 1997, would make HIV a manageable disease for most who received treatment. The term "barebacking" came into use to refer to a conscious decision to discard condoms, at first an exceptional position that soon spread. Most ongoing prevention programs, unequal to the new epidemic, simply tinkered with the safer sex workshops of an earlier generation. A slow rise in HIV incidence for gay guys continued until the recent acceleration captured in the latest incidence report.

There's no good evidence that current HIV prevention programs work, so federal and local governments have cut funding for prevention that targets HIV-negative people at risk. People who are HIV-positive, when effectively treated, achieve an undetectable amount of HIV in the blood and are much less infectious. So "Treatment as Prevention" (TasP) has become a popular notion in the world of AIDS. But 20 percent of HIV-infected Americans -- and over 50 percent of HIV-infected young gay men -- don't know it. People are least likely to know they are HIV-positive shortly after seroconversion, when they're most infective. And only 28 percent of Americans living with HIV sustain an undetectable viral load. So treatment of HIV-positive people, while laudable work, will not itself eliminate new HIV infections anytime soon. The trend away from engaging HIV-negative people in prevention efforts misses an opportunity and accepts as inevitable many thousands of seroconversions. A more rational model of HIV care would reach across the divide of serostatus to deliver testing, counseling and treatment to the at-risk HIV-negative population.

In this HIV prevention emergency the queer community has been abandoned. Mainstream gay organizations shelved AIDS as an issue more than a decade ago. In 2010 only 3.3 percent of the CDC's discretionary AIDS budget went to MSM, who account for nearly two thirds of new infections. A new wave of HIV activists will have to sound the alarm and reassert, even in an age of effective treatments, the value in remaining HIV-negative. Knowing one's HIV status is the first step to making smarter sex decisions. Too few young queers do. We'll have to pressure departments of health to invest in widespread testing, integrated into the daily lives of gay men and trans women -- or we'll have to develop such programs ourselves. Community members have to start a big conversation about the sex we're having, about serostatus, about how we can have our pleasure and maintain our health. It will take queer people to devise targeted, sex-positive, queer-friendly "smarter sex" outreach.

The community's knowledge about prophylactic, or preventive, HIV drugs is shockingly low. If you're HIV-negative and had anal sex without a condom or the condom broke, you can prevent HIV infection with a 28-day course of medication, post-exposure prophylaxis (PEP), provided you act quickly. HIV-negative people whose behavior puts them at continued risk for HIV exposure are eligible for pre-exposure prophylaxis (PrEP), a daily dose of HIV drugs that greatly reduces risk if taken as directed. Prevention activists will have to get the word out about these drugs, even as they demand that the CDC and local departments of health fund information campaigns that target at-risk sub-groups, community doctors and emergency rooms about HIV prevention drugs.

Twenty-one years ago, some treatment activists from ACT UP/NY, the best-known and largest AIDS activist organization, broke away to form the Treatment Action Group, TAG. Activists on both sides of the divide did important work that led to effective AIDS treatments. On Pride Day some of us will be marching together again in the ACT UP contingent, along with a fresh generation of activists, the first steps in an HIV prevention campaign that we hope will help reverse the frightening rise in new cases of HIV infection. We cannot surrender half of a new generation to the virus that stole so many from the last.

Thanks to ACT UP's James Krellenstein, who crunched some of the numbers for this blog post.